Courage Catwalk 2025: A Celebration of Strength and Resilience

For the second consecutive year, Solis proudly partnered with the Breast Cancer Foundation (BCF) as the presenting sponsor of the Courage Catwalk event, held on 7 March 2025 in conjunction with International Women’s Day. This year’s theme, Cultural Mosaic of Courage, was a powerful reminder that breast cancer does not discriminate —it affects individuals of […]
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Breast Cancer Screening Guidelines: A Guide for General Practitioners in Singapore

Breast cancer is the most common cancer among women in Singapore, with one in 13 women expected to be diagnosed in their lifetime. As general practitioners (GPs) play a vital role in early detection, it is crucial to understand the national screening guidelines and the rationale behind them. Our consultant radiologist, Dr Eugene Ong, provides an overview of breast cancer screening recommendations, including why screening starts at 40, the role of ultrasound, the differing screening intervals for various age groups, and key imaging concepts such as BI-RADS and indeterminate lesions. Screening and Diagnosis Early Detection through regular screening can significantly increase the chances of successful treatment and survival. By detecting breast cancer at an early stage, treatment options are usually less invasive, and the prognosis is generally more favourable. Note: Age recommendations are only guidelines and may differ for those with a family history of breast cancer or those who have other risk factors. Supplementary ultrasound may be ordered to increase the accuracy of screening. 1. Why Screen at 40 Years Old vs. 50 Years Old? Early Detection: Screening from age 40 allows earlier detection of breast cancer, which is crucial as breast cancer can develop before 50. Studies have shown that Asian women, including Singaporean women, tend to develop breast cancer at a younger age compared to Western populations. Higher Incidence in Younger Women: In Singapore, a not-insignificant proportion of breast cancer cases occur in women in their 40s. Screening from 40 helps detect cancers earlier when they are more treatable. Survival Benefit: Early detection through screening in women aged 40–49 has been associated with improved survival rates and reduced mortality. Government Guidelines: The Ministry of Health (MOH) and the Singapore Cancer Society recommend mammogram screening starting at 40, with different screening intervals depending on age (see point 3). 2.  Why Screen with Ultrasound – Why Isn’t Ultrasound in the MOH Guidelines, Only Mammograms? Mammograms are the Gold Standard: Mammography is the only breast screening method with proven mortality reduction in large-scale population screening. It effectively detects microcalcifications, which can be an early sign of breast cancer. Ultrasound as a Supplemental Tool: Ultrasound is useful in women with dense breasts (common in younger women and Asian populations) as mammograms may miss some cancers in dense breast tissue. However, ultrasound alone is not a primary screening tool because it is operator-dependent and can lead to higher false positives. MOH Guidelines Prioritize Evidence-Based Screening: Since large-scale randomized trials have not proven ultrasound as an effective stand-alone screening tool, it is not included in national guidelines. However, in clinical practice, ultrasound is often recommended as an adjunct to mammography, especially for women with dense breasts. 3. Why Do We Do Increasing Intervals for Mammogram Screening (Annually for 40-49 Years, Every 2 Years for 50+)? Changes in Breast Tissue Composition: Glandular tissue appears white on mammograms, while fatty tissue appears black. As women age, glandular tissue involutes and is replaced by fatty tissue. Challenges in Detecting Cancer in Younger Women: Since breast cancers also appear white on mammograms, they can be more easily obscured by dense glandular tissue in younger women. More frequent mammograms (annually from 40-49 years) help improve detection. Improved Visibility in Older Women: As women age, their breasts contain more fatty tissue, providing better contrast for detecting white cancerous lesions against the black fatty tissue background. Hence, mammograms can be performed less frequently (every two years from 50 onwards). 4. What is an Indeterminate Lesion? Definition: An indeterminate lesion is a breast abnormality detected on imaging that cannot be definitively classified as benign or malignant. It requires further evaluation, which may include additional imaging (e.g., ultrasound, MRI) or biopsy. Examples: Small solid masses, complex cysts, or lesions with ambiguous features on mammography or ultrasound. Follow-up: Some indeterminate lesions will require further evaluation by breast specialists, while others may need biopsy to confirm the diagnosis. 5. What is BI-RADS? When you undergo a mammogram, ultrasound or MRI, our radiologists categorise the findings to communicate the recommended follow up actions. Your report will likely include a BI-RADS score, which is a standardised system used to classify findings and guide recommendations. BI-RADS (Breast Imaging- Reporting and Data System) is a standardised system developed by the American College of Radiology (ACR) to categorise breast imaging findings and their level of suspicion for malignancy ranging from 0 to 6. At times, it may be difficult to classify findings into BI-RADS 0-6, so some centres use descriptive terms instead- such as benign, probably benign, indeterminate, or suspicious. This helps guide the breast surgeon on the next steps. [Ref: American College of Radiology] 3D Mammogram vs 2D Mammogram Mammograms are X-ray images of the breast used to detect tumours or abnormalities, and are the most common screening tool for breast cancer. During a mammogram, your breasts are compressed between two plates to capture clear images. While this may be uncomfortable, mammograms are quick and generally painless. This article has been reviewed by Dr Eugene Ong, Consultant Radiologist at Luma Women’s Imaging Centre
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Keyhole Mastectomy : the Key to the Future?

A recent study compared two types of mastectomies: the conventional nipple-sparing mastectomy (NSM) and keyhole methods (using endoscopic or robotic approaches) [1] Conducted across five tertiary hospitals in Taiwan, the study involved 73 conventional NSM cases and 160 keyhole NSM of which 84 cases used endoscopic approach and 76 cases with robotic assistance. Here’s what it revealed about the pros and cons of these methods. What Are Keyhole Surgeries? Keyhole surgeries, also known as minimal access surgeries, involve making small incisions and using specialised long thin instruments e.g. a wand-like camera to assist with the procedures. These methods are common in abdominal and pelvic keyhole surgeries, where they have revolutionised care by reducing post-operative pain, recovery times and complications[2]. In breast surgery, however, keyhole approaches are still evolving and has not replaced the conventional NSM as the standard of care. Study Findings: How Do These Approaches Compare?  The study revealed several key points[1]: Surgery Time and Recovery: All approaches had similar operating times and recovery periods. In skilled hands, keyhole methods could be faster. Wound Healing: Smaller scars (4 cm vs. 9 cm) and better healing were observed in keyhole surgeries, with fewer cases of delayed healing. Complications: All approaches had low complication rates, and overall safety was similar. Patient Satisfaction: Patients in all groups reported high satisfaction with their results, including psychosocial and physical well-being, for instance skin sensation, arm function and minimal or no chronic pain. Costs: Robotic surgeries were more expensive than conventional and endoscopic methods. To date, conventional mastectomy remains the standard of care due to the following reasons: Easier Accessibility and Surgeon Expertise: Conventional mastectomy is widely accessible because it does not require specialised equipment like robotic and endoscopic systems, making it suitable for hospitals with limited resources. Most surgeons are already familiar and experienced in the conventional approach: ensuring reliable and consistent results. Comprehensive Cancer Removal for Complex Cases: The conventional approach offers direct access, visualisation and tactile appreciation of the surgical site, enhancing the surgeon’s ability to ensure complete cancer removal. This makes it particularly effective for complex cases, such as advanced or multifocal cancers, where extensive tissue removal is necessary to ensure oncologic safety. Simplified Reconstruction Options: The larger incision in conventional NSM allows easier access for various immediate breast reconstruction options, providing more surgical flexibility in terms of reconstructive options Proven Long-Term Outcomes: With a long-established track record, conventional mastectomy has demonstrated consistent effectiveness and safety in breast cancer treatment. Cost-Effectiveness and Lower Maintenance Costs: Conventional NSM costs less than robotic or endoscopic surgeries, as it avoids the additional and often high costs of advanced equipment. Hospitals also benefit from reduced maintenance expenses, further enhancing its cost-effectiveness. Versatility Across Patient Profiles: Conventional NSM is highly adaptable, making it suitable for a wide range of patients, including larger advanced cancers involving skin, the patient’s physical habitus or unique anatomical considerations. Unlike minimal access approaches, it has fewer technical constraints, ensuring broader eligibility. Mastectomy Rates Around the World and in Singapore Globally, mastectomy rates vary widely due to differences in healthcare practices, cultural attitudes, access to reconstructive surgery and alternative treatments like breast-conserving surgery (BCS) and radiotherapy. For average-risk women in USA, overall mastectomy rates are 31% with a rising trend of double mastectomies of up to 49% in certain states[3][4]. Such a trend was not observed in Europe, as reported by an Italian study where mastectomy rates have remained stable at 34% with no increase in women opting for double mastectomies[5]. In Singapore – mastectomy rates have remained consistently high over the past two decades. A review over a 10-year period in a single institution from 2001 to 2010 reported mastectomy rates remained high throughout the period, varying between 43% and 59%[6]. Separately another review from another local institution reported 70% of patients treated during the same period underwent mastectomy with a low rate (1.25%) of double mastectomies[7]. Who Needs a Mastectomy? Mastectomy is often necessary for women with large tumours or widespread cancer within the breast. However, advances in cancer screening and treatment have reduced the need for mastectomy in many cases. In Singapore, most breast cancers diagnosed today are small (under 2 cm)[8], making breast-conserving surgery (removing the tumour while preserving the breast) a welcoming option for most patients. For larger cancers, modern therapies like pre-surgery treatments (neoadjuvant therapy) can shrink tumours, allowing many women to avoid mastectomy altogether[9][10]. On the other hand, genetic testing has led to greater awareness and a trend of more healthy but at-risk women considering double mastectomies as a preventive strategy to lower their cancer risk[11]. Special considerations for Scar Concealment in Conventional Mastectomies Increasingly, surgeons have focused on concealing scars wherever possible during conventional mastectomies. Dr. Esther Chuwa from Solis Breast Care & Surgery emphasises, “Surgical scars are a necessity with any surgery: most patient are able to accept that. But by placing incisions in well-hidden areas like the skin folds beneath the breast, we can minimise its visibility while ensuring that oncologic safety is maintained. This approach contributes immensely to patients feeling more confident and hopeful during their recovery as visually, they are not constantly reminded of their diagnosis” This approach ensures that oncologic principles, including adequate tumour removal, are not compromised while simultaneously addressing the patient’s aesthetic and emotional concerns.  Considering these factors plays a significant role in enhancing the emotional well-being and overall recovery of breast cancer patients. Looking Ahead While keyhole surgeries offer smaller scars and potentially better wound healing, conventional mastectomy remains a trusted and effective choice for breast cancer surgery. As technology advances, keyhole approaches may gain momentum in replacing the conventional approach as the standard of care, but for now, the conventional approach continues to deliver excellent outcomes for most patients. The future of breast surgery is bright, with ongoing research exploring new tools and techniques to improve care. Whether through minimal access or conventional methods, the goal remains the same: safe, effective, and personalised treatment for every patient. Article contributed and reviewed by Dr Esther Chuwa, Senior Consultant and Breast Surgeon at Solis Breast Care & Surgery References: [1] Lai HW et al. Robotic Versus Conventional or Endoscopic-assisted Nipple-sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-reported Outcomes (RCENSM-P). Ann Surg. 2024 Jan 1;279(1):138-146. [2] Velanovich V. Laparoscopic vs open surgery: A preliminary comparison of quality-of-life outcomes. Surg Endosc. 2000;14:16–21. [3] Kummerow KL, Du LP, Penson DF, Shyr Y, Hooks MA Nationwide trends in mastectomy for early stage breast cancer. JAMA Surg. 2015;150(1):9-16. [4]  Steiner, C.A., Weiss, A.J., Barrett, M.L., Fingar, K.R. and Davis, P.H. (2016) Trends in Bilateral and Unilateral Mastectomies in Hospital Inpatient and Ambulatory Settings, 2005-2013. HCUP Statistical Brief #201. Agency for Healthcare Research and Quality.  [5] Fancellu A et al. Mastectomy patterns, but not rates, are changing in the treatment of early breast cancer. Experience of a single European institution on 2315 consecutive patients. Breast. 2018 Jun;39:1-7.  [6] Chan PM et al. Mastectomy rates remain high in Singapore and are not associated with poorer survival after adjusting for age. SpringerPlus 2015 Nov 10;4:685.  [7] Sim YR et al. Contralateral prophylactic mastectomy in an Asian population: a single institution review. Breast. 2014;23(1):56–62.  [8] Singapore Cancer Registry Annual Report 2022 [9] Golshan M et al. Impact of neoadjuvant therapy on eligibility for and frequency of breast conservation in stage II-III HER2-positive breast cancer: surgical results of CALGB 40601 (Alliance). Breast Cancer Res Treat 2016;160:297-304 [10] Golshan M et al. Impact of neoadjuvant chemotherapy in stage II-III triple negative breast cancer on eligibility for breast-conserving surgery and breast conservation rates: surgical results from CALGB 40603 (Alliance). Ann Surg 2015;262:434-9 [11] Wong, Stephanie M. MD et al. Growing Use of Contralateral Prophylactic Mastectomy Despite no Improvement in Long-term Survival for Invasive Breast Cancer. Annals of Surgery 265(3):p 581-589, March 2017
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